Primary care networks build on the core of current primary care services and enable the greater provision of proactive, personalised, coordinated, and more integrated health and social care.
Primary care networks are based on GP-registered lists, typically serving natural communities of around 30,000 to 50,000.
service requirements in 2023/24
A PCN must provide enhanced access between the hours of 6.30pm and 8pm Mondays to Fridays and between 9am and 5pm on Saturdays.
A PCN must
- provide bookable clinical appointments that
- are available to all PCN Patients
- are for any general practice services and services pursuant to the Network Contract DES
- are available a minimum of two weeks in advance
- are delivered by a multi-disciplinary team of healthcare professionals
- are a mixture of in person face to face and remote (telephone, video or online) appointments
- are in locations that are convenient for the PCN’s patients to access in person face-to-face services
- ensure GP cover during the Network Standard Hours
A PCN must
- provide a minimum of 60 minutes of appointments per 1,000 PCN adjusted patients per week
- make the Network Standard Hours appointment book accessible to the Core Network Practices
- make same day online booking for available routine appointments where no triage is required up until as close to the slot time as
- operate a system of enhanced access appointment reminders
- provide patients with a simple way of cancelling enhanced access appointments at all times
- make available to NHS111 any unused on the day slots during the Network Standard Hours from 6.30pm on weekday evenings and between 9am-5pm on Saturdays, unless it is agreed with the commissioner that the timing for when these unused slots are made available is outside of these hours
- have in place appropriate data sharing and, where required data processing arrangements
- actively communicate availability of these enhanced access appointments to their patients
A PCN must
- use appropriate tools to identify and prioritise the PCN’s Patients who would benefit from a structured medication review
- offer and deliver a volume of SMRs determined and limited by the PCN’s clinical pharmacist capacity
- ensure invitations for SMRs provided to patients explain the benefits of, and what to expect from SMRs
- clearly record all SMRs within GP IT systems
- work with community pharmacies to connect patients appropriately to the New Medicines Service which supports adherence to newly prescribed medicines
- actively work with its CCG in order to optimise the quality of local prescribing of
- antimicrobial medicines
- medicines which can cause dependency
- metered dose inhalers, where a lower carbon device may be appropriate
- nationally identified medicines of low priority
- The cohort must include patients
- In care homes
- with complex and problematic polypharmacy
- on medicines commonly associated with medication errors
- with severe frailty, who are particularly isolated or housebound patients, or who have had recent hospital admissions and/or falls
- using one or more potentially addictive medications from the following groups: opioids, gabapentinoids, benzodiazepines and z-drugs
A PCN must
- have agreed with the commissioner the care homes for which the PCN will have responsibility
- have in place with local partners a simple plan about how the Enhanced Health in Care Homes service will operate
- support people entering, or already resident in the PCN’s Aligned Care Home, to register with a practice in the aligned PCN
- ensure a lead GP (or GPs) with responsibility for these Enhanced Health in Care Homes service requirements is agreed
- work with community service providers and other relevant partners to establish and coordinate a multidisciplinary team
- have established arrangements for the MDT to enable the development of personalised care and support plans
- have in place established protocols between the care home and with system partners for information sharing, shared care planning, use of shared care records, and clear clinical governance
- deliver a weekly ‘home round’
- In delivering the round, the PCN must
- prioritise residents for review according to need based on MDT clinical judgement and care home advice
- have consistency of staff in the MDT
- include appropriate and consistent medical input from a GP or geriatrician
- use digital technology to support the weekly home round and facilitate the medical input
- In developing support plans, the PCN must
- aim for the plan to be developed and agreed with each new patient within seven working days of admission to the home and within seven working days of readmission following a hospital episode
- develop plans with the patient and/or their carer
- base plans on the principles and domains of a Comprehensive Geriatric Assessment including assessment of the physical, psychological, functional, social and environmental needs of the patient including end of life care needs where appropriate
- draw on existing assessments that have taken place outside of the home and reflecting their goals
A PCN must
- review referral practice for suspected and recurrent cancers, and work with its community of practice to identify and implement specific actions to improve referral practice, particularly among people from disadvantaged areas where early diagnosis rates are lower
- work with local system partners to agree the PCN’s contribution to local efforts to improve uptake in cervical and bowel NHS Cancer Screening Programmes and follow-up on non-responders to invitations
- focus on prostate cancer to develop and implement a plan to increase the proactive and opportunistic assessment of patients for a potential cancer diagnosis in population cohorts where referral rates have not recovered to their pre-pandemic baseline
- review use of non-specific symptom pathways, identifying opportunities and taking appropriate actions to increase referral activity
- adopt and embed
- the requesting of FIT tests where appropriate for patients being referred for suspected colorectal cancer
- the use of teledermatology to support skin cancer referrals
A PCN must
- provide the PCN’s Patients with access to a social prescribing service
A PCN must
- improve diagnosis of patients with hypertension
- undertake activity to improve coverage of blood pressure checks, by
- increasing opportunistic blood pressure testing where patients do not have a recently recorded reading
- undertaking blood pressure testing at suitable outreach venues
- working pro-actively with community pharmacies to improve access to blood pressure checks, in line with the Community Pharmacy Blood Pressure Check Service
A PCN must
- improve the identification of those at risk of atrial fibrillation
- identify patients at high risk of Familial Hypercholesterolaemia and make referrals for further assessment where clinically indicated
- offer statin treatment to patients with a QRISK2&3 score >= 10%
- support the earlier identification of heart failure (HF), through building awareness among PCN staff around the appropriate HF diagnostic pathway, and early identification processes for HF including the timely use of N-terminal pro B-type natriuretic peptide (NTProBNP) testing
A PCN must
- undertake network development and quality improvement activity to support CVD prevention including
- reviewing outputs from CVD intelligence tools and sharing key learning amongst PCN staff
- supporting the development of system pathways for people at risk of CVD through liaison with wider system partners
- collaboration with commissioners to improve levels of diagnostic capacity for ‘ABC’ testing, including availability of ambulatory blood
pressure monitors (ABPMs) and electrocardiogram (ECG) monitors
- ensuring processes are in place to support the exchange of information with community pharmacies, including a process for
accepting and documenting referrals between pharmacies and GP practices for the Community Pharmacy Blood Pressure Check Service
A PCN must
- identify and include all patients with a learning disability on the learning disability register, and make all reasonable efforts to deliver an annual learning disability health check and health action plan for at least 75% of these patients who are aged over 14
- record the ethnicity of all patients registered with the PCN
- appoint a lead for tackling health inequalities within the PCN
- review its identification of a population within the PCN experiencing inequality in health provision and/or outcomes, and ensure there is a plan to tackle the unmet needs of that population
A PCN and commissioner must have jointly
- utilised available data on health inequalities to identify that selected population, working in partnership with their ICS, including local medical or pharmaceutical committees, and local authority commissioners
- held discussions with local system partner organisations who have existing relationships with the selected population to agree an approach to engagement
- held engagement with the selected population to understand the gaps in, and barriers to their care
- defined an approach for identifying and addressing the unmet needs of this population
A PCN must
- contribute to ICS-led conversations on the local development and implementation of Anticipatory Care
A PCN must
- review its targeted programme to proactively offer and improve access to social prescribing to an identified cohort with unmet needs
- review its sample audit of the PCN’s Patients’ current
experiences of shared decision making through use of a validated tool and its documenting of its consideration and implementation of any improvements to SDM conversations made as a result
service requirements in 2020/21
Requirements for the delivery of EHCHs by primary care networks (PCNs) are included in the 2020/21 Network Contact DES and associated guidance, with corresponding requirements for community health services and other NHS providers in the NHS Standard Contract. These requirements were fully implemented from 1 October 2020, including:
- every care home being aligned to a named PCN
- every care home having a named clinical lead
- a weekly ‘home round’ or ‘check in’ with residents prioritised for review based on MDT clinical judgement and care home advice (this is not intended to be a weekly review for all residents)
- within 7 days of re/admission to a care home, a resident will have a person-centred holistic health assessment of need (will include physical, psychological, functional, social and environmental needs of the person and can draw on existing assessments that have taken place outside of the home, as long as it reflects their goals)
- within 7 days of re/admission to a care home, a resident will have in place personalised care and support plan(s), based upon their holistic assessment
- the Network Contract DES also has a contractual requirement to prioritise care home residents who would benefit from a Structured Medication Review (SMR).
The Enhanced Health in Care Homes Framework has been updated to support the delivery of the minimum standards described in these contracts, and sets out practical guidance and best practice for CCGs, PCNs and other providers and stakeholders as they work collaboratively to develop a mature EHCH service, and should be read alongside these contractual requirements.
Structured medication reviews and medicines optomisation
Structured Medicine Reviews (SMRs) are an evidence-based and comprehensive review of a patient’s medication, taking into consideration all aspects of their health. In a structured medication review clinicians and patients work as equal partners to understand the balance between the benefits and risks of and alternatives of taking medicines. The shared decision-making conversation being led by the patient’s individual needs, preferences and circumstances.
Problematic polypharmacy is where, for an individual taking multiple medicines, the potential for harm outweighs any benefits from the medicines and/or they do not fully understand the implications of the medication regime they are taking. This includes:
- medicines that are no longer clinically indicated or appropriate or optimised for that person
- combination of multiple medicines has the potential to, or is actually causing harm to the person
- practicalities of using the medicines become unmanageable or are causing harm or distress.
SMRs have benefits to people taking multiple medicines:
- improved experience and quality of care through being involved in the decision-making process and having a better understanding of the medicines they take
- less risk of harm from medicines (e.g. adverse drug events, side effects, hospitalisation or addiction)
- better value for local health systems (e.g. reduced medicine waste).
Across England, general practices are working together with community, mental health, social care, pharmacy, hospital and voluntary services in their local areas in primary care networks (PCNs). Professionals are working together to support patients with structured medication reviews as one of the PCN service requirements which commenced during 2020/21.
From October 2020, all PCNs are required to identify patients who would benefit from a SMR, specifically those:
- in care homes;
- with complex and problematic polypharmacy, specifically those on 10 or more medications;
- on medicines commonly associated with medication errors;
- with severe frailty, who are particularly isolated or housebound or who have had recent hospital admissions and/or falls;
- using potentially addictive pain management medication.
The number of patients to be offered a SMR will depend upon the PCN’s clinical pharmacist capacity. Further information on the expectations of PCNs and more detailed clinical guidance, for example from the Royal Pharmaceutical Society and NHS Scotland can be found in the Network Contract DES SMR guidance.
service requirements in 2021/22
From 1st Oct PCNs must confirm or exclude hypertension where blood pressure exceeds thresholds in GP and community settings, including reviewing patient records of previous elevated blood pressure. From 1st Oct PCNs must improve coverage of checks including opportunistic testing and aligning with the Community Pharmacy hypertension service.
From 1st Oct PCNs must identify and include all learning disability patients and patients with SMI on the respective registers and make reasonable efforts to deliver the set percentage of health checks. By 31st Dec PCNs and Commissioners must jointly identify a population experiencing inequality in provision/outcome and begin engagement. By 28th Feb PCNs must have a finalised plan to tackle this unmet need and proceed to deliver this from 1st March.
service requirements in 2022/23
In 2022/23 the CVD requirements expand to include atrial fibrillation, heart failure and familial hypercholesteremia, and requires quality improvement activity to support CVD prevention.
early cancer diagnosis
Service requirement 1: review referral practice for suspected and recurrent cancers, and work with their community of practice to identify and implement specific actions to improve referral practice, particularly among people from disadvantaged areas where early diagnosis rates are lower.
Service requirement 2: work with local system partners – including the NHS England and NHS Improvement Regional Public Health Commissioning team and Cancer Alliance – to agree the PCN’s contribution to local efforts to improve uptake in cervical and bowel NHS Cancer Screening Programmes and follow-up on non-responders to invitations. This must build on any existing actions across the PCN’s Core Network Practices and include at least one specific action to engage a group with low participation locally.
Service requirement 3a: work with its Core Network Practices to adopt and embed the requesting of FIT tests where appropriate for patients being referred for suspected colorectal cancer
Service requirement 3b: work with its Core Network Practices to adopt and embed where available and appropriate, the use of teledermatology to support skin cancer referrals (teledermatology is not mandatory for all referrals)
Service requirement 4: focusing on prostate cancer, and informed by data provided by the local Cancer Alliance, develop and implement a plan to increase the proactive and opportunistic assessment of patients for a potential cancer diagnosis in population cohorts where referral rates have not recovered to their pre-pandemic baseline.
Service requirement 5: review use of their non-specific symptoms pathways, identifying opportunities and taking appropriate actions to increase referral activity.
By 30 September 2022, a PCN must ensure all clinical staff complete the Personalised Care Institute’s 30-min e-learning refresher training for Shared Decision Making (SDM) conversations.
By 30 September 2022, as part of a broader social prescribing service, a PCN and commissioner must jointly work with stakeholders including local authority commissioners, VCSE partners and local clinical leaders, to design, agree and put in place a targeted programme to proactively offer and improve access to social prescribing to an identified cohort with unmet needs. This plan must take into account views of people with lived experience.
From 1 October 2022, commence delivery of the proactive social prescribing service for the identified cohort.
By 31 March 2023, a PCN must audit a sample of their Patients’ current experiences of shared decision making through use of a validated tool and must document their consideration and implementation of any improvements to SDM conversations made as a result.
By 31 March 2023 review cohort definition and extend the offer of proactive social prescribing based on an assessment of the population health needs and PCN capacity.
From April 2022 PCNs will deliver a single, combined extended access offer funded through the PCN DES. Further detail to be published this autumn.